COMMON COMPLICATIONS OF GYNECOLOGIC PROCEDURES
The Authors examined gynecologic procedures complications
With the advent of same-day surgery and the increasing necessity to discharge patients within 3 days of a major procedure, postsurgical gynecologic patients are presenting to emergency departments with increasing frequency. The objective of this chapter is to provide an overview of the common complications of gynecologic procedures likely to lead to an emergency department visit and the diagnostic and therapeutic approach to these patients.
COMMON COMPLICATIONS OF ENDOSCOPIC PROCEDURES
Laparoscopy
Gynecologic laparoscopy, both diagnostic and therapeutic, involves the use of a rigid endoscope, which is inserted usually through a small subumbilical incision bluntly into the abdominal cavity. Prior to the insertion of the laparoscope, the abdomen is insufflated with nitrous oxide or carbon dioxide gas administered through a small-diameter verres needle.
Laparoscopy can be used to diagnose existing pelvic disease and to perform simple and complex gynecologic surgeries. With advanced technology and increased operator skill, the laparoscope is currently used for laser ablation of endometriosis and pelvic adhesions, sharp lysis of adhesions, linear salpingostomy or salpingectomy for the treatment of ectopic pregnancy, laser ablation of small myomata, oophorectomy, cystectomy, laparoscope-assisted vaginal hysterectomy, and retropubic urethropexy.
All these procedures have the same potential complications, but the more complicated surgeries carry considerably more risk. The major complications associated with the use of the laparoscope are (1) thermal injuries to the bowel; (2) bleeding at the site of tubal interruption or sharp dissection; and (3) rarely ureteral and/or bladder injury, large bowel injury, and pelvic hematoma or abscess.
Of these complications the most serious and dreaded is that of thermal injury to the bowel. This injury occurs most commonly in the terminal ileum, although injuries to the rectosigmoid and colon have been reported. Various series have reported the incidence of electrothermal injuries to be in the range of 0.5 to 3.2 per 1000 cases. The injury that goes unrecognized presents the most serious problem. These patients generally appear 3 to 7 days postoperatively, depending upon the degree of necrosis, with signs and symptoms of peritonitis, including bilateral lower abdominal pain, fever, elevated white cell count, and direct and rebound tenderness. X-rays may show an ileus or free air under the diaphragm. Although gas has been used to insufflate the abdomen, it should be absorbed totally within 3 postoperative days. Patients who have increasing pain after laparoscopy, either early or late, have a bowel injury until proved otherwise. If thermal injury is a serious consideration and cannot be distinguished from other causes of peritonitis, it is best to err on the side of early laparotomy.
Traumatic bowel injury is less problematic than thermal injury. This is because it is usually caused by the very small diameter verres needle and is recognized when the needle is withdrawn. Peritonitis rarely develops following this complication, and hospital revisits are uncommon.
Bleeding may occur with any laparoscopic procedure, but due to direct visualization, it is usually arrested during the original procedure.
Infection has not been a frequent or particularly serious complication of laparoscopy. Excluding minor incisional infection, pelvic infection is reported in fewer than 1 per 1000 cases. When pelvic infection does occur, it is probably secondary to a subacute coexisting infection present prior to the procedure or secondary to the introduction of skin contaminants. Its presentation is not unique. Broad-spectrum antibiotic treatment provides a rapid response.
Infection dehiscence and herniations of the laparoscopic abdominal incision are rare but have been reported. Infection is usually treated with drainage. Dehiscence usually involves protrusion of the omentum and, in rare cases, the small bowel through the opening. Immediate wound reclosure is usually sufficient, provided no bowel injury has occurred and there is no evidence of infection.
Hysteroscopy
Hysteroscopy involves the direct investigation of the interior of the uterine cavity using a rigid or flexible fiberoptic instrument. It can be carried out in an office procedure using the contact or flexible hysteroscope or under IV sedation or general anesthesia using the panoramic hysteroscope. It is used for both diagnostic and therapeutic purposes. Indications for use include investigation of any intrauterine pathology, i.e., endometrial polyps, submucous myomata, and foreign bodies. Therapeutic applications include directed biopsies, removal of small myomata, endometrial ablation using laser for menorrhagia, and division of small uterine septae or synechiae.
Complications of hysteroscopy fortunately are rare; they include: (1) reaction to the distending media, (2) uterine perforation, (3) cervical laceration, (4) anesthesia reaction, (5) intraabdominal organ injury, (6) infection, and (7) postoperative bleeding.
Postoperative bleeding will be the most likely cause of hospital revisit. Surgical procedures that could result in postoperative uterine bleeding include lysis of adhesions, resection of myomata, and YAG laser obliteration of the endometrium. After hemodynamic stabilization of the patient, an intrauterine tampon such as a pediatric foley generally can control this problem. Occasionally reexploration to cauterize a bleeding area is necessary. Rarely, abdominal control of the bleeding is required.
Infection as a result of the hysteroscopic procedure is uncommon; considering the number of cases done, the most severe infection, tuboovarian abscess, has rarely been reported. Treatment should be commensurate with presentation and symptoms.
Damage to intraabdominal contents has been reported. The seriousness of these complications ranges from the inconsequential rupture of a hydrosalpinx to damage to the bowel at the time of intrauterine biopsy, uterine perforation, or laser ablation. These are not common and generally are eliminated by the concomitant use of laparoscopy. Should injury go unrecognized, it would present as described.
Uterine perforations are mentioned only because they are a relatively common complication associated with the procedure but seldom require more than observation.
COMPLICATIONS RELATED TO MAJOR ABDOMINAL PROCEDURES
Those complications that would lead to an emergency department visit would, by their nature, present more than 3 days postoperatively. Late-onset complications include, but are not confined to, wound infection and related morbidity, phlebitis (superficial and deep), urinary tract infection, ileus and bowel obstruction, and ureteral or bladder injury.
Wound Infection
Clinical Features
Wound infection may occur as late as several months following surgery, but more than 90 percent of the cases present within the first 2 weeks. The first sign is usually fever followed by tachycardia and varying degrees of increased tenderness. As the infection progresses, the wound may be fluctuant or firm. The incision is swollen, erythematous, edematous, and tender. There may be spontaneous purulent drainage from the wound. Initial management consists of opening the wound and probing with a cotton-tipped swab to ensure the fascia is intact, then allowing the wound to drain. If the patient has been discharged with staples in place, the wound opens easily after staple removal. If the staples have been removed, gentle probing will open the wound. Aerobic and anaerobic wound cultures should be obtained for use if the patient does not respond rapidly. Once a wound infection has been opened or drained, care is directed toward debridement and packing with saline-soaked gauze or half-strength peroxide.
Patient Disposition
Rarely are antibiotics required unless there is an underlying cellulitis. Readmission is common practice, at least for observation and patient teaching.
Wound Hematoma
Clinical Features
Hematomas are a common complication of wound closure that are more frequent in transverse than vertical incisions. The wound itself may swell and be painful, but in general, the smaller hematoma can and should be managed expectantly. If there are any signs of infection, the wound should be managed accordingly. The patient should be instructed to return if signs of infection develop.
Wound Seroma
Clinical Features
Wound seromas are relatively uncommon in the gynecologic incision, with the exception of groin dissection. It is, by definition, a collection of serous fluid, which may drain spontaneously. In general, it is the presence of drainage, not fever or pain, that brings the patient to the emergency department. If the wound remains intact after gentle probing, the seroma can be watched and usually will disappear. Wound infection precautions should be given.
Dehiscence and Evisceration
Clinical Features
Dehiscence is a failure of normal healing and locally means disruption of any layers of a surgical incision. Clinically, dehiscence connotes disruption of all layers, including fascia but not peritoneum. Evisceration occurs when there is complete breakdown of the healing processes through all levels of the abdominal wall, with the omentum or bowel presenting through the incision.
Diagnosis
The classic sign of impending wound disruption is the sudden outpouring of serosanguinous blood from the abdominal incision. Most often this occurs between postoperative days 5 and 8. The patient may describe a pop or tearing sensation. About one-third of the cases of wound dehiscence will be associated with evisceration. When evisceration has occurred, the abdomen should be covered with moist sterile towels and supported with tape to prevent further extrusion of the gut.
Patient Disposition
The patient should be taken directly to the operating room for closure. In those cases in which there is a sudden appearance of blood but no bowel, it is best to follow the same procedure because evisceration usually is imminent.
Ureteral Injury
Clinical Features
Operative injury to the ureter results from one of three types of trauma: crushing, transection, and ligation. Each type of injury may be either partial or complete. This complication occurs more often during the performance of abdominal hysterectomy than in any other pelvic surgery. Unilateral ureteral injury usually is discovered within 48 to 72 h postoperatively but may go undiscovered for up to 2 to 3 weeks. Occasionally, permanent and complete occlusion will lead to renal atrophy without symptoms.
Diagnosis
In most instances, ureteral injury produces symptoms of fever, flank pain, and costovertebral angle tenderness. These symptoms may indicate pyelitis, but if the patient has unexplained or persistent fever, persistent abdominal distension, unexplained hematuria, or especially escape of a watery discharge, an intravenous pyelogram (IVP) should be obtained. Further indications for an IVP include oliguria or the appearance of a lower abdominal or pelvic mass following pelvic surgery. If the diagnosis is made 2 to 3 weeks postoperatively, percutaneous nephrostomy with delayed repair is the treatment of choice.
MISCELLANEOUS COMPLICATIONS OF MAJOR GYNECOLOGIC PROCEDURES
Cuff Cellulitis
Clinical Features
Cuff cellulitis refers to infections of the contiguous retroperitoneal space immediately above the vaginal apex and including the surrounding soft tissue. It is a common complication following both abdominal and vaginal hysterectomy. It usually produces a fever between postoperative days 3 to 5 and thus, generally, will delay discharge of the postabdominal hysterectomy patient. The postvaginal hysterectomy patient conceivably will have been discharged, as such patients are being discharged within 12 h postoperatively. These women present with a complaint of fever and lower quadrant pain. Pelvic tenderness and induration are prominent during the bimanual examination. A vaginal cuff abscess may be palpable.
Patient Disposition
The treatment of choice is readmission, drainage, and intravenous antibiotics.
Urinary Retention
Voiding difficulties in the healthy female are uncommon. However, many women experience either an inability to void or incomplete emptying of the bladder during the postoperative period.
Clinical Features
Inability to void is more frequent after operations that involve the urethra and bladder neck, i.e., anterior repair or any modification of the retropubic urethropexy. Most problems with voiding following any of these procedures resolve with time and without medication.
Patient Disposition
If mechanical obstruction is not suspected to be a factor, intermittent straight catheterization is the treatment of choice. The patient should be instructed to attempt to void on a timed schedule, with an interval of less than 3 h. She should be discharged with instructions for self-catheterization should she be unable to void and be reassured that voiding function will return in time.
Postconization Bleeding
Clinical Features
Treatment of high-grade squamous intraepithelial lesions of the cervix may be treated by LEEP (loop electrocautery), laser vaporization, or cold knife care. The most common complication associated with these procedures is bleeding. If delayed hemorrhage occurs, it usually occurs 7 days postoperatively. Bleeding following this procedure can be rapid and severe.
Patient Disposition
Visualization of the cervix is the key to controlling such bleeding. Application of Monsel's solution is a reasonable first step if it is easily available. Usually, however, suturing of the bleeding arteriole is necessary. Quite often, the patient must be taken to the operating room for repair secondary to poor visualization.
Induced Abortion
Induced Abortion There are three major methods for termination of pregnancy: instrumental evacuation by the vaginal route, stimulation of uterine contraction, and major surgical procedures. Vacuum evacuation of the uterus has been associated with immediate and delayed complications. Immediate complications include uterine perforation, hemorrhage, and cervical laceration. Delayed complications of all methods of abortion include retention of products of conception, causing bleeding, infection, and possibly thrombophlebitis.
The majority of immediate complications will be arrested at the time of the abortion; however, uterine perforation, if unrecognized, could be complicated further by injury of intraabdominal contents with the suction. If this should occur and go unrecognized, the patient will present with the appropriate signs of organ injury. The organ most commonly injured is the bowel; however, the ureter has been injured as a consequence of this mishap. Management of these complication was discussed previously.
Advanced gestation abortion may result in injury to the uterus and infundibulopelvic or ovarian artery from the large dilators used in these procedures. If performed in a freestanding clinic, catastrophic blood loss could result in a true emergency. Resuscitation, replacement of blood loss, and emergency surgery are essential in the prevention of maternal mortality. If a patient with an injury of this nature is being transferred, pretransfer notification of the gynecology service may save valuable time.
Retained products of conception and a resulting endometritis are far more common complications.
Clinical Features
The patient usually will present 3 to 5 days posttermination with complaints of excessive bleeding, fever, and abdominal pain. She may not present for up to 2 weeks. Pelvic examination reveals a subinvoluted tender uterus with foul-smelling blood vaginally. An elevated white blood count is common.
Patient Disposition
Treatment must include evacuation of intrauterine contents and intravenous antibiotic therapy. Triple antibiotic therapy is the standard; however, there is increasing evidence that ampicillin with sulbactam is equally as effective. If the patient has pain, bleeding, or both, but unaccompanied by fever, ectopic pregnancy must be ruled out. The presence of villi on the pathology report (if available) confirms the presence of an intrauterine gestation but cannot rule out the rare occurrence of both ectopic and intrauterine gestations.
- Brooks P: Complications of operative hysterorscopy: How safe is it? Clin Obstet Gynecol 35:256, 1992.
- Daly JW: Dehiscence, evisceration and other complications. Clin Obstet Gynecol 31:754, 1988.